By the end of 2025, more than 270 generic drugs were still in short supply across the U.S. healthcare system. These aren’t rare specialty meds-they’re the pills and injections millions rely on every day: antibiotics, IV fluids, chemotherapy drugs, epinephrine, heparin. And the reason they’re running out isn’t because of a sudden spike in demand. It’s because the system that makes and moves them is broken.
Why Generic Drugs Are the First to Go Missing
Generic drugs make up 90% of all prescriptions filled in the U.S., but they only account for about 13% of total drug spending. That’s because they’re cheap. Really cheap. Some sterile injectables cost less than $5 per dose. That low price sounds good for patients and insurers-but it’s a death sentence for manufacturers trying to stay in business.When a company can only make a few cents profit per unit, there’s no money left for quality control upgrades, backup equipment, or extra inventory. If a factory in India gets shut down by an FDA inspection-or a tornado hits a plant in Kentucky-there’s no cushion. No one else is making it, because no one else can afford to.
Compare that to brand-name drugs. Companies like Pfizer or Merck spend billions on R&D, so they charge more. That lets them build global supply chains with multiple factories, stockpile raw materials, and absorb cost spikes. Generic makers? They’re running on fumes.
The Global Bottleneck: Where Your Medicine Comes From
Almost 40% of the active ingredients (APIs) in U.S. drugs come from China. Another big chunk comes from India. These countries produce APIs at a fraction of the cost because labor is cheaper, regulations are looser, and scale is massive.But here’s the catch: the FDA has known for years that many of these facilities have inconsistent quality. In 2023, a single inspection failure in India halted production of cisplatin, a key chemotherapy drug. The result? Nationwide shortages that delayed cancer treatments for months.
And it’s not just one plant. For many older generics, manufacturing has collapsed down to just one or two factories worldwide. That’s not a supply chain-it’s a single point of failure. If that one line goes down, the whole country runs out.
Sterile Injectables: The Most Fragile Link
Not all drugs are created equal. Oral pills are simple to make. Sterile injectables? They’re a whole different beast.IV fluids, antibiotics, and cancer drugs that go directly into the bloodstream must be made in ultra-clean rooms, with air filtered to near-surgical standards. The equipment is expensive. The process takes longer. The margin for error is zero. One tiny contamination, and the entire batch is destroyed.
That’s why sterile injectables make up the majority of drug shortages. In 2024, over half of all shortages involved injectables. A tornado in 2023 knocked out a Pfizer facility that produced 15 different injectable medications. No one else could step in fast enough. Patients went without.
Who Pays the Price?
It’s not just hospitals that feel the crunch. Patients do too.Doctors have to swap one drug for another-even if it’s less effective, has more side effects, or isn’t approved for their patient’s condition. Pharmacists spend 20 to 30% of their workweek tracking down alternatives, compounding meds by hand, or rationing doses. Nurses delay treatments. Surgeries get canceled. Cancer patients wait weeks for their next infusion.
One hospital pharmacist in Ohio told a reporter they once had to stretch a single vial of epinephrine across three emergency cases because there was no backup. That’s not medicine. That’s triage.
Why Solutions Keep Failing
Politicians talk about bringing drug manufacturing back to the U.S. It sounds good. But it’s not that simple.Rebuilding domestic production for critical generics would take 5 to 7 years and cost between $20 and $30 billion. There aren’t enough trained workers. The FDA can’t inspect new plants fast enough. And even if you build them, who will run them profitably when the market still demands $3-per-dose prices?
Proposed tariffs on Chinese and Indian APIs? They might sound like a fix-but they’ll just make drugs more expensive, and likely cause more shortages as manufacturers cut back to stay competitive.
Some lawmakers want mandatory six-month stockpiles of essential drugs. But who pays for that? Hospitals? Taxpayers? The system isn’t designed to hold inventory-it’s designed to squeeze every penny out of every pill.
What’s Actually Being Done?
There are signs of movement. The FDA has started cracking down harder on foreign manufacturers with poor records. The Department of Health and Human Services is pushing for more transparency-requiring labels that say where APIs come from.Some states are experimenting with public-private partnerships to fund production of high-risk generics. The Association of Accessible Medicines is pushing for incentives to keep manufacturers in the game. But progress is slow. Federal agencies are understaffed. Regulations are outdated. And without a major shift in how we pay for these drugs, nothing will change.
The Real Problem Isn’t Geography-It’s Economics
This isn’t a problem of trade policy or national security. It’s a problem of value.We treat life-saving generic drugs like commodities, not essentials. We expect them to be cheap, but we don’t pay enough to make them reliably. We blame China or India, but the real failure is ours: a system that rewards low prices over resilience, and punishes anyone who tries to do the right thing.
Until we accept that some medicines can’t be made for $2.50 a dose-and start paying what it actually costs to produce them safely-we’ll keep seeing the same shortages. The same delays. The same scared patients and overworked nurses.
It’s not about where the pills are made. It’s about whether we’re willing to make sure they’re always there when someone needs them.